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Skype Study Research was conducted regarding the use of Skype for evaluation and treatment in the medical/legal field. This study was last updated in February of 2016. 1. Information was found from www.Skype.com regarding their security and privacy policies: The following information was found from: http://www.skype.com/en/security/#encryption

What we do to keep you safe Encryption overview

The internet, like any network, can be monitored by criminals and hackers at any number of points. This is one of the reasons why email and many internet chat programs are not secure. As there are so many ways for unknown persons to monitor your communications, you must take positive steps to protect yourself from these malicious third parties. Encryption is the process of converting information, using principles of mathematics, in such a way that it is readable only by the intended recipient after they have converted the information back. Many kinds of encryption techniques have been developed over the centuries. This process is called encryption and decryption and forms part of the security discipline called cryptography. As far back as 1900 BC the Egyptians utilized non standard hieroglyphs to protect a message; whilst the Greeks in 490 BC used strips of leather wrapped around a specific length and width of staff. This process of disguising a message is called cryptography. Julius Caesar possibly created and used the world‘s first substitution cipher. Through shifting each letter a fixed amount, for example 'a' becoming 'e', 'b' becoming 'f' and so on, resulted in unintelligible words and messages. The approach of applying rules to a message and the result of a separate encoded message is called a cipher. The key to unlocking the hidden message was knowing the offset of which to shift the letters; forward to encode and backwards to decode. These ciphers, whilst primitive now, were at the forefront of cryptography at their time but as with any advancement greater technological resources and knowledge

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can be used both to further a subject but also to work against it. As past ciphers can now be defeated trivially, modern ciphers must also continue to evolve. Here at Skype we use standard internationally recognized and accepted encryption algorithms that have withstood the test of time over many years of analysis and attacks. This protects your communications from falling into the hands of hackers and criminals. In so doing, we help ensure your privacy as well as the integrity of the data being sent from you to your contacts. Digital Identity and Encryption in Skype One of Skype's main goals is to protect you from malicious attackers eavesdropping on your communications. In addition, we want to prevent the kind of impersonation that fraudsters often use over email (for instance phishing) to trick users into giving up valuable personal information. To achieve these goals, Skype issues everyone a "digital certificate" which is used to establish and confirm both the identity of the person placing and receiving a Skype call or chat. What is a Digital Certificate? A digital certificate is an electronic credential that can be used to establish the identity of a Skype user, wherever that user may be located. Just like a physical identity document, such as a driving license, a digital certificate must have certain properties in order to be used as a form of identification. In particular, it must: Name the specific account being identified. Be issued by an authority that can revoke the certificate at any time. Be difficult to counterfeit. Contain the countersignature of the issuing authority, which, in this case, is Skype. Authentication As each Skype user possesses a digital credential, it is possible for any Skype user to verify the identity of any other Skype user. This process is called authentication, the proving of each party's identity to the other. In order to gain access to this digital certificate your Skype Name and password is confirmed. It is therefore imperative that you follow our guidelines for keeping your Skype Name and password secure. Authentication is a critical step in ensuring secure communications. Imagine having a conversation with someone who claimed to be a business partner, but who is actually an impostor. The conversation could be strongly encrypted as normal yet the divulging of private information could still occur.

Encryption Communications networks, such as the internet, can be monitored by criminals and hackers at any number of points. This is one of the reasons why email and

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many internet chat programs are considered unsafe from a security point of view. In other words, because there are so many ways for unknown persons to monitor users' communications, users must take positive steps to protect themselves from this type of intrusion. Encryption is the process of encoding a message, using principles of mathematics, in such a way that it is readable only by the intended recipient. Many kinds of encryption techniques have been developed over the centuries, but they all tend to resemble a lockbox and key; once a secret message is put into the lockbox and secured with the key, it can only be read again by someone possessing the same key. The key can be something known or even a physical object, such as the length and width staff as mentioned above. For Skype your key is your Skype Name and password, hence the criticality of keeping that safe. Skype uses well-known standards-based encryption algorithms to protect Skype users' communications from falling into the hands of hackers and criminals. In so doing, Skype helps ensure user's privacy as well as the integrity of the data being sent from one user to another.

The following information was found from: http://www.skype.com/en/legal/privacy/

COLLECTING YOUR INFORMATION Skype collects many kinds of information in order to operate effectively and provide you the best products and experiences we can. Some of this information you provide directly to us. Some of it we collect when you interact with our websites, software, products and marketing communications. Some of it is available from other sources that we may combine with the data we collect directly. Regardless of the source, we believe it's important to treat that information with care and to help you maintain your privacy. What we collect: -Information you provide to us directly, such as when you sign up, modify your profile or sign into Skype. Not all information is required, but if certain information is not provided, you may not be able to use some products or features. This information includes: Identification data, such as contact information for you and your Skype contacts, including name, username, address, telephone number, mobile number, and email address. -Profile information, such as your age, gender, country and city of residence, language preference, avatar, URL of videos in your mood message, other information provided as part of creating a Microsoft or Skype account and any information that you choose to make available to others as part of your Skype user profile;

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-Banking and payment information, such as your credit card number or other account number; -Signing in - to access Skype software, you will need to sign in with your Skype or Microsoft username and password. By signing in on one Microsoft site or service with a Microsoft account, you may be automatically signed into other Microsoft websites and services that use Microsoft account. Click here for more Microsoft account privacy information. -Usernames and passwords for other services, for example, when you choose to allow Skype to use contact lists from other services to populate your Skype contacts or to search for your friends on Skype. Please note that we will not use your usernames and passwords for any other purpose and will not retain your usernames and passwords after using them for these purposes. -Correspondence between you and Skype. Using our websites, software and products – we collect information that tells us how you interact with our websites, software, products, and marketing communications. This information includes:

-Computer or device information, such as IP address, cookie IDs, manufacturer‘s name, device model number or unique identifier, operating system, browser type, connection information, device capabilities, bandwidth and (if applicable) carrier network; -Usage information, such as the products you have ordered, web pages you have viewed and links you click; traffic data (which is data processed in connection with the conveyance of communications or billing and includes the duration and time of the call, the number or username calling and the number called), call quality data; software performance and interaction information; error reports; Skype Wi-Fi enabled hotspot detection and usage statistics. -Test calls made to ECHO123, which are recorded and played back to the user and then deleted. -Contents of instant messages, voicemails, and video messages. -Information about available and connected Wi-Fi connections -Location information derived from your mobile carrier or from your mobile device see Location Based Services for more detail. -Access tokens for other accounts you associate with your Skype account (such as Microsoft account or Facebook), which are like an electronic key provided by the service that acts in place of a password for authentication.

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-Data from other sources - We may get additional information about you, such as demographic data we purchase from other companies. How we collect: We use a number of methods and technologies to gather information about how you use our websites, software and products, such as:

-Web forms, such as when you type information into a registration form or type a search query into a search box. -Technologies like cookies and web beacons; -Web logging, which enables us to collect the standard information your browser sends to every website you visit - such as your IP address, browser type and language, and the site you came from - as well as the pages you visit and the links you click while using our websites and products. -Skype software installed on your device, which may send back information.

USING YOUR INFORMATION Skype uses the information we collect to operate, improve and personalize Skype and other Microsoft software, products, and features. For example, information that you provide as part of your Skype profile may be included in the search directory to enable other users of Skype (or products that interact with Skype, such as Skype for Business) to search for you and connect with you. Information collected through Skype may be combined with information collected through other Microsoft products and services to give you a more consistent and personalized experience in your interactions across Microsoft products and services. We may also supplement this with information from other companies. For example, we use services from other companies to help us derive a general geographic area based on your IP address in order to customize certain features or offers to your geographic area. We also may use the information to communicate with you, for example, informing you when a subscription is ending, letting you know when security updates are available, letting you know when you need to take action to keep your account active, or to organize and carry out marketing or promotional operations/offers, contests, games and similar events. We provide many of our products, software and features free of charge because they are supported by advertising. The information we collect may be used to help improve the advertisements you see by making them more relevant to you.

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We also use the information to resolve disputes and protect your interests, as well as Skype‘s and Microsoft‘s interests, including, in particular enforcing Skype‘s Terms of Use and preventing and fighting against fraud. SHARING YOUR INFORMATION We will share your personal information with third parties with your consent. For example, we share your content with third parties when you tell us to do so, such as when you send a message to a contact using Skype. We may share or disclose personal information with other Microsoft controlled subsidiaries and affiliates; and, as necessary, with partners (e.g. telecom carriers, Wi-Fi access services providers, distributors of Skype software and/or Skype products, third party banking organizations or other providers of payment services) and with vendors or agents working on our behalf. For example, companies we've hired to provide customer service support or assist in protecting and securing our systems and products may need access to personal information in order to provide those functions. In such cases, these companies must abide by our data privacy requirements and are not allowed to use the information for any other purpose. We may also transfer your data to Microsoft Corporation, who may use it for purposes consistent with those described in this privacy statement. Moreover, we may disclose personal information as part of a corporate transaction such as a merger or sale of our assets. We may access, disclose and preserve your personal information, including your private content (such as the content of your instant messages, stored video messages, voicemails or file transfers), when we have a good faith belief that doing so is necessary to: -comply with applicable law or respond to valid legal process from competent authorities, including from law enforcement or other government agencies (or to assist our local partner, operator or company facilitating your communication to do the same); -protect our customers, for example to prevent spam or attempts to defraud users of the services, or to help prevent the loss of life or serious injury to anyone; operate and maintain the security of our services, including to prevent or stop an attack on our computer systems or networks; or -protect the rights or property of Skype and Microsoft, including enforcing the terms governing the use of products – however, if we receive information indicating that someone is using our products to traffic in stolen intellectual or physical property of Skype or Microsoft, we will not inspect a customer‘s private content ourselves, but we may refer the matter to law enforcement.

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To summarize, Skype uses well-known standards-based encryption algorithms to protect Skype users' communications from falling into the hands of hackers and criminals. In so doing, Skype helps ensure user's privacy as well as the integrity of the data being sent from one user to another. Skype does collect content from instant messages, voicemails, and video messages; however, Skype will only share this information when Skype feels that it is in good faith in order to comply with applicable law or respond to valid legal process from competent authorities, including from law enforcement or other government agencies, protect our customers, for example to prevent spam or attempts to defraud users of the services, or to help prevent the loss of life or serious injury to anyone; operate and maintain the security of our services, including to prevent or stop an attack on our computer systems or networks. Please note, we do not use Skype for the purposes of instant messages, voicemails, and video messages. Again, video calls are not recorded or stored by Skype, and video calls are highly protected by Skype’s internationally recognized methods of encryption.

2. Research was also conducted on http://www.zurinstitute.com/skype_telehealth.html. In the article titled, Utilizing Skype to Provide TeleMentalHealth, E-Counseling, or E-therapy: Reviewing the debate on Skype & HIPAA Compliance by Ofer Zur, Ph.D., the following information was found:

Skype and HIPAA Compliance: Encryption, Business Associate, HITECH In order to evaluate whether Skype is HIPAA compliant or not, one must look at three issues: Encryption, Business Associate, and HITECH Act of 2011. Encryption: When it comes to HIPAA compliance, Skype utilizes the AES encryption protocol, which meets the Federal Information Processing Standards (FIPS) for electronic transmission under HIPAA. Skype has implemented a variety of physical, technical and administrative safeguards, including encryption techniques, which protect or can protect the confidentiality and security of the Protected Health Information (PHI) that may be transmitted using Skype's calling and video calling products. A minimal level of encryption, often spoken of by knowledgeable professionals, is 128-bit encryption. Skype's 256-bit encryption technique meets this requirement… Several experts noted that it is harder to hack into Skype than into most telephone lines or brick and mortar offices and file cabinets. One must remember that hacking into Skype requires high expertise and skills. Hacking into Skype is much harder than simpler, low-tech and cheaper technologies, such as hidden recording devices in one's therapy office, electromagnetic emission keystroke loggers, etc.

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3. Research was also conducted on http://www.psychiatrictimes.com/blog/telepsychiatry-perils-using-skype. In the article titled, Telepsychiatry: The Perils of Using Skype by Marlene M. Maheu, Ph. D. and Joseph Mcmenamin, M.D., J.D., the following information was found:

Conclusion This area of the law is still in a relatively primitive state. It is apt to change considerably over time. Practitioners offering services at a distance are well advised to keep abreast of developments in the field, and to adapt their practices accordingly.

4. Research was also conducted on http://www.theconnectivist.com/2013/08/skype-your-depression-away/. In the article titled, Skype Your Depression Away by Taylor Kubota, the following information was found:

According to a new study from the University of Zurich, Internet-based psychotherapy is just as effective—and perhaps even more effective—than face-to-face psychotherapy for the treatment of depression… According to the American Telemedicine Association, there are now around 200 telemedicine networks that service some 3,000 care sites. While phones are still in use by some providers, telehealth tech has greatly expanded. High-quality video conferencing seems to be the system of choice but some programs use chats or emails. Others have even developed in-home text systems so health care providers can quickly check in with patients about their day-to-day wellbeing… Many people are skeptical of Internet-based health care but Dr. Birgit Wagner, co-author of the study, says ―they shouldn‘t be worried that online therapy is less effective than face-to-face therapy.‖ In this case, it may even be superior.

5. Based upon the previous article, research was conducted regarding the study completed at the University of Zurich at http://www.mediadesk.uzh.ch/articles/2013/psychotherapie-via-internet-wirkt-gleich-gut-oder-besser-wie-im-sprechzimmer_en.html. The following data was found in the study:

Psychotherapy via internet as good as if not better than face-to-face consultations Online psychotherapy is just as efficient as conventional therapy. Three months after the end of the therapy, patients given online treatment even displayed fewer symptoms. For the first time, clinical researchers from the University of Zurich provide scientific evidence of the equal value of internet-based psychotherapy…

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Six therapists treated 62 patients, the majority of whom were suffering from moderate depression. The patients were divided into two equal groups and randomly assigned to one of the therapeutic forms. The treatment consisted of eight sessions with different established techniques that stem from cognitive behavior therapy and could be carried out both orally and in writing. Patients treated online had to perform one predetermined written task per therapy unit – such as querying their own negative self-image. They were known to the therapist by name… Three months after completing the treatment, the depression in patients treated online even decreased whereas those treated conventionally only displayed a minimal decline: no more depression could be detected in 57 percent of patients from online therapy compared to 42 percent with conventional therapy.

6. Research was also conducted on http://pro.psychcentral.com/2013/telepsychiatry-ready-for-prime-time/004372.html. In the article titled, Telepsychiatry: Ready for Prime Time? by Daniel Carlat, M.D., the following information was found:

The first concern we all have is whether Skype is secure and is ―HIPAA compliant.‖ HIPAA requires that you take reasonable precautions to keep medical information confidential, and Dr. Barta believes that Skype is secure enough to meet that standard. He points out that Skype uses AES—the Advanced Encryption Standard, approved by the National Security Agency for the transmission of top secret information. According to Barta, ―If you‘re willing to talk to patients on your cell phone, you should be willing to talk to them on Skype.‖

7. Research was also conducted with CourtCall, Remote Court Appearances, a company that does Remote Court Appearances based out of Los Angeles, California. CourtCall serves Judges and Attorneys nation-wide. Their website is: http://www.courtcall.com/ccallp/main?c=CCHOME

―CourtCall created the turn-key telephonic court appearance industry in 1995. Lawyers hoping to help reduce the cost of litigation know that clients save hundreds, if not thousands, of dollars each time their lawyers are not required to sit in traffic or jump on a plane or train for a brief appearance. CourtCall was created because there was a compelling need to make routine, non-evidentiary pre-trial appearances more cost effective for clients and more manageable for busy attorneys. CourtCall enables attorneys to seamlessly simulate an in-person court appearance with no discernible disruption in the business of the Court, all at no cost to the Court. Cut down on time, money and pollution - CourtCall is available in hundreds of State, Federal, Bankruptcy and Provincial Courts across the US and Canada and may be used from virtually anywhere in the world.‖

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CourtCall is a nationwide company with approximately four hundred ninety (490) participants nationwide. The following is a shortened list of participating courts in the State of California that are utilizing CourtCall, Remote Court Appearances. This list was updated in June of 2015:

San Francisco Superior Court – San Francisco U.S. District Court-N.D. California (San Francisco) – San Francisco U.S. Bankruptcy Court-N.D. California (San Francisco) – San Francisco JAMS - California - San Francisco – San Francisco Alameda County Superior Court-Alameda – Alameda San Mateo County Superior Court – Redwood City U.S. Bankruptcy Court-N.D. California (Oakland) – Oakland U.S. District Court-N.D. California (Oakland) – Oakland Alameda County Superior Court-Oakland – Oakland Alameda County Superior Court-Berkeley – Berkeley Alameda County Superior Court-Hayward HOJ – Hayward Marin County Superior Court – San Rafael JAMS - California - Walnut Creek – Walnut Creek Contra Costa County Superior Court – Martinez Santa Clara County Superior Court – San Jose JAMS - California - San Jose – San Jose U.S. District Court-N.D. California (San Jose) – San Jose U.S. Bankruptcy Court-N.D. California (San Jose) – San Jose Workers' Compensation Appeals Board - San Jose – San Jose Napa County Superior and Municipal Courts – Napa Solano County Superior Court – Fairfield Santa Cruz County Superior Court – Santa Cruz Workers' Compensation Appeals Board - Santa Rosa – Santa Rosa U.S. Bankruptcy Court-N.D. California (Santa Rosa) – Santa Rosa Sonoma County Superior Court – Santa Rosa Workers' Compensation Appeals Board - Stockton – Stocton San Joaquin County Superior Court – Stockton Workers' Compensation Appeals Board - Salinas – Salinas Monterey County Superior Court – Monterey San Benito County Superior Court – Hollister Stanislaus County Superior Court – Modesto U.S. Bankruptcy Court-E.D. California (Modesto) – Modesto Yolo County Superior Court – Woodland U.S. Bankruptcy Court-E.D. California (Sacramento) – Sacramento U.S. District Court-E.D. California (Sacramento) – Sacramento Sacramento County Superior Court – Sacramento JAMS - California - Sacramento – Sacramento Workers' Compensation Appeals Board - Sacramento – Sacramento

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8. The following published article was purchased online, and reviewed for content: A qualitative study on the use of Skype for psychotherapy consultations in the Ukraine, by Sisira Edirippulige, Marina Levandovskaya, and Anna Prishutova.

―Summary There has been rather limited use of Skype for health and medical purposes. We investigated the use of Skype for delivering psychotherapy services in the Ukraine. A provider questionnaire was distributed to all delegates (n=50) at the Annual Symposium of Psychotherapists. One copy of a client questionnaire was also given to each service provider and they were instructed to request their next client to complete the survey. In total, 29 providers and 23 clients responded to the questionnaire. The majority of clients (61%) and providers (72%) had used Skype for a range of services. The services they provided were related to a wide range of paradigms including psycho-analysis, psycho-drama, Gestalt therapy, cognitive behavioral therapy and existential therapy. A key reason for using Skype was to allow practitioners to contact clients who were not easily accessible, e.g. those who lived in other countries. Most practitioners (n=24) thought their clients considered the services received on Skype were good or excellent. All 26 practitioners charged for Skype consultations. The majority of clients and providers showed high satisfaction with the use of Skype for psychotherapy services.‖ ―A study that used Skype to provide lactation consultations to mothers (n=12) found that the technique was very useful. Another study that carried out functional assessment using Skype compared it with outpatient reviews, and found no clinically significant differences in the outcomes. The authors concluded that Skype can be used as an alternative to goniometry in clinical settings. A survey of patients showed that 93% of patients (n=29) preferred the use of Skype for follow-up, mainly due to the convenience and cost-saving involved.5 Another study aimed at testing the usefulness of Skype for transferring real-time pathology images for interpretation by experienced pathologists. The study found a high concordance between surgical pathologists.‖ ―One important requirement for conducting successful video consultations is the availability of clear video images and audio. Studies have shown that the ability to carry out successful teleconsultations depends on the quality of video and audio.7 Clinician and patient satisfaction of video consultations are also often dependent on the quality of the connection. A number of studies have shown that high quality videoconferencing with commercial videoconferencing equipment and reliable networks such as ISDN can facilitate telemedicine consultations. However, such systems are not universally available and are often expensive. Skype is free and easily available. Due to the popularity of Skype for general communication, many people are familiar with it.‖ ―Our study showed a key reason for using Skype was to allow practitioners to contact clients who were not easily accessible. A number of practitioners noted that they often used Skype to contact people who live in distant places, including

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those who live in other countries. Many people moved away from the Ukraine after the disintegration of the Soviet Union, but they retain a desire to use services from familiar mental health professionals. Skype provides both practitioners and clients with an acceptable medium for communication. Clients pointed out a number of advantages provided by Skype, mainly that they can access services regardless of distance. For some clients this was the only possible way of receiving such a service.‖ ―Some providers mentioned that they could not undertake certain aspects of therapies by Skype due to poor video and audio quality. Therefore the practitioners were selective in the use of Skype for the most suitable aspects of their practice.‖ ―The use of Skype for medical and health practices is an example of adapting a commonly available technology for delivering care services. It seems reasonable to assume that tools such as Skype will become more widely used in future.‖

9. The following published article was purchased online, and reviewed for content: Skype: a tool for functional assessment in orthopaedic research, by Daniel W. Good, Darren F. Lui, Michael Leonard, Seamus Morris, and John P. McElwain.

―Summary Skype is a free program which enables PC users to make video calls to other users with Internet access. We carried out a prospective review of all acromioclavicular joint hook plates for lateral-third clavicle fractures over a five-year period. Functional assessment with Oxford and Constant shoulder scores were carried out using Skype and compared to outpatient review using the Bland-Altman method. Of 36 patients (mean age 36 years), 33 had a computer with a video camera, all 33 had Internet access and 22 were already users of Skype. In total 29 patients were happy to take part in Skype assessment (83%). In comparison with outpatient review, there was a mean difference in the Oxford score of 20.48 (95% confidence interval 20.84, 20.12); the mean difference for the Constant score was 20.68 (95% confidence interval 21.08, 20.29). These differences were not clinically significant, confirming that Skype can be used as an alternative to goniometry in this clinical setting. A survey showed that 93% of 29 patients surveyed preferred the use of Skype for follow-up, mainly due to the convenience and cost-saving involved. The study demonstrates the potential for this new technique in providing patients with more options for follow-up.‖ ―Skype is a free, secure program which enables PC users to make telephone and video calls to other PC users via the Internet. Users only require an Internet connection, PC, video camera and microphone, items which are commonly available in many homes. The aim of the present study was to evaluate the use of Skype in assessing the functional outcome of patients undergoing clavicle hook plate fixation for displaced lateral third clavicle fractures.‖

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―Discussion It is becoming increasingly difficult to conduct functional outcome studies of patients after surgery, because of falling research budgets, increased outpatient waiting lists and the reluctance of patients to return for review due to the time and cost of getting to hospital. Many studies are limited by a lack of follow-up which can lead to nonresponder bias. The cost to the patient is often underestimated by doctors. This has led to an increase in the popularity of postal questionnaires. However questionnaires are subjective and do not provide the same face validity as an outpatient review.‖ ―The results of our patient satisfaction survey showed that 93% of patients assessed with both methods preferred the use of Skype to outpatient review. The reasons stated were that it was more convenient, and that patients saved money on transport to hospital. A previous study has shown significant cost to the patient of travel into hospital. Skype assessment does require relatively expensive equipment (a computer, video camera, speakers and Internet access). However most of our patients (83%) already had the necessary equipment and the Skype software is free. The potential cost-saving is an advantage of Skype over traditional methods.‖ ―Another important matter for the possible widespread use of Skype in the evaluation of patients is its security. Skype uses encryption, cryptography, a digital certificate and authentication to maintain security and prevent data theft. These measures are described elsewhere. Whilst Skype is a secure network, patients should be made aware of the potential for unauthorized access to their health information if Skype‘s security is compromised.‖ ―Despite these potential sources of errors, our study has shown that Skype can accurately determine the Oxford and Constant shoulder scores compared with goniometry in OPD. We believe that using Skype has the potential to be more reliable than goniometry if a standardized procedure is used. This is because in goniometry the examiner has to hold goniometers over bony landmarks whilst a patient tries to maintain the same position. Having a protractor superimposed on a still picture is a technically simpler procedure and therefore more reproducible. Whilst further studies are required to investigate the technique in different joints and to measure intra- and inter-tester reliability, we believe our study demonstrates the potential for this new technique in providing patients with more options for follow-up.‖ ―In conclusion, Skype allows home follow-up of patients following hook-plate insertion. The study showed that for our patients, it was preferable to outpatient review because the patients felt that it saved time and money. Skype enables face validity, which is not available with telephone/postal questionnaires. Our study was performed on a small number of patients and a larger study is required to confirm the findings. However, the technique has the potential to bring an outpatient consultation and functional outcome assessment to large numbers of patients in future.‖

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10. The following published article was purchased online, and reviewed for content: Clinical Social Work in a Digital Environment: Ethical and Risk-Management Challenges, by Frederic G. Reamer.

―Digital technology has created unprecedented options for the delivery of clinical social work services. Increasing numbers of clinicians are relying fully or partially on various forms of digital and other technological options to serve people who are struggling with a wide range of challenges, including mood disorders, anxiety, addictions, and relationship issues. Clinical practice is no longer limited to office-based, in-person meetings with clients. Today large numbers of clinical social workers are using video counseling, email chat, social networking websites, text messaging, avatar-based websites, self-guided web-based interventions, smartphone apps, and other technology to provide clinical services to clients, some of whom they never meet in person (Chester and Glass 2006; Kanani and Regehr 2003; Lamendola 2010; Menon and Miller-Cribbs 2002; Reamer 2012a, 2013a; Zur 2012). Some social workers are using digital technology informally as a supplement to traditional face-to-face service delivery. Other practitioners have created formal ‗distance‘ clinical practices that depend entirely on digital technology.‖ ―Many clinical social workers celebrate their ability to enhance clients‘ access to services using digital and other distance counseling tools and believe they can do so in a way that honors and adheres to prevailing ethical standards in social work (Dowling and Rickwood 2013; Mattison 2012). They argue that distance counseling services offer a number of compelling advantages. Some individuals who want clinical services live in remote geographic areas and would have great difficulty traveling to a social worker‘s office. Physically disabled clients can use distance counseling options without enduring the logistical challenges and discomfort involved in arranging transportation and traveling significant distances. Individuals with overwhelming anxiety and agoraphobia can access help from home that they might not seek otherwise. People who are profoundly concerned about protecting their privacy — especially if they are well known in their local community — can receive counseling without risking exposure in a clinician‘s waiting room. The 24/7/365 availability of counseling services, given the options people have to ‗connect‘ with a clinician somewhere in the world almost immediately any time of day or night, either online or by smartphone, also enhances social workers‘ ability to help people in crisis.‖ ―Conclusion Clinical social work has been transformed by the emergence of digital and other electronic technology. Most contemporary social workers completed their formal education and entered the profession before currently available technology was invented, at a time when clinical relationships were limited to ongoing face-to-face meetings and the in-person development of a therapeutic alliance. Today‘s practitioners have the capacity to counsel clients they never meet in person. Even social workers who maintain traditional office-based clinical practices have the

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option to interact with clients outside the office using video counseling technology, email, text messaging, and avatars. For some clinicians and clients, the traditional in-office therapeutic hour has become an anachronism; the boundaries of the clinician-client relationship are now much less clear and much more fluid and ambiguous.‖

11. The following published article was purchased online, and reviewed for content: Cognitive Behaviour Therapy, Effectiveness of Cognitive Behavioral Therapy Administered by Videoconference for Posttraumatic Stress Disorder, by Vanessa Germain , André

Marchand , Stéphane Bouchard , Marc‐Simon Drouin & Stéphane Guay.

―Abstract. Telehealth, or health care via videoconferencing, constitutes a clinical option that makes it possible to treat patients remotely. A growing number of studies have demonstrated that telehealth is a feasible and effective method for diagnostic interviews and psychiatric consultations. However, few studies have assessed the effectiveness of psychotherapy given by videoconference. This study examines the effectiveness of cognitive behavioural therapy (CBT) administered by videoconference for posttraumatic stress disorder (PTSD). Forty-eight participants with PTSD were recruited for the study: 16 in the videoconferencing condition and 32 in a control face-to-face condition. Each participant received CBT for 16 to 25 weeks and completed various questionnaires before and after treatment. The results show a significant decline in the frequency and severity of posttraumatic symptoms after treatment in both conditions. A clinical improvement in overall functioning was also observed. No significant difference was observed in the effectiveness of the two therapeutic conditions. The examination of effect sizes supports these results. A number of clinical implications and certain avenues for future research are discussed.‖ ―Access to health care services is a growing concern, and for this reason telehealth, or treatment via teleconferencing, constitutes a viable option to provide certain services remotely. Recourse to remote treatment provides many advantages, such as increased and quicker accessibility to health care services for people who live outside major urban centers as well as reduced wait lists, travel time, and transportation costs. Appropriate use of telehealth could contribute to mitigating the unequal distribution of resources. However, few studies have specifically assessed the effectiveness of remote psychotherapy, particularly via a videoconferencing system.‖ ―Discussion The results of this study do not show any significant differences in the effectiveness of CBT administered by videoconference or face-to-face to individuals with PTSD. Participants in both conditions improved significantly between the beginning and the end of their therapy with regard to posttraumatic symptomatology, level of anxiety and depression, level of functioning in different domains of everyday life, and perception of their physical as well as mental health.‖

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―The results of this study are very promising because they support the effectiveness of videoconferencing psychotherapy, which may increase the availability of effective psychological services for people who do not have access to psychological services for a multitude of reasons. Nevertheless, it is important to assess the effectiveness of telepsychotherapy for different disorders, in addition to assessing the personal characteristics of clients that could affect the outcome of treatment. Considering that not all therapeutic approaches can easily be applied remotely, future research will have to evaluate the efficiency with which certain treatments can be applied by videoconference. Finally, although it would be unrealistic and undesirable to replace all traditional services by this new technology, it is important to make an effort to demystify this type of intervention and make it accessible. For instance, a study by Rees and Stone (2005) indicates that psychologists still have numerous prejudices against remote treatments. In this study, 30 psychologists conducted psychotherapy by means of videoconference or face-to-face therapy. After therapy, each psychologist evaluated the therapeutic alliance between the therapist and the client. The results demonstrate that, even though the therapy was identical for both conditions (e.g., verbatim, appearance of the therapists), the therapists who delivered videoconferencing therapy judged the therapeutic alliance less positively compared with the therapists in the face-to-face condition. According to the authors, the therapists believed that videoconferencing can have a negative impact on the development of the therapeutic alliance by affecting a therapist‘s demonstration of warmth, sensitivity, empathy, and comprehension. Despite certain limitations and prejudices, videoconferencing has been shown to be effective. For this reason, researchers and psychologists need to overcome these negative beliefs and work to improve technical limitations in order to increase accessibility to these services.‖

12. The following published article was reviewed online: Telepsychology or TeleMentalHealth in the Digital Age: The Future Is Here, by Ofer Zur, Ph.D. http://www.zurinstitute.com/telementalhealth.pdf

―Telehealth, also referred to as Telemedicine or E-Health, is a general term describing the delivery of medicine via digital means rather than an in-person situation. For psychotherapy counseling and mental health services, it has been called TeleMental-Health, TelePsychology, E-Counseling, E-Psychotherapy, TelePsychiatry, Internet-based psychotherapy, TeleAnalysis, and similar names. TeleMentalHealth is generally defined as the use of the telephone, text, e-mail, chats, interactive tele-video-conferencing technologies, or virtual reality (VR) for the assessment and treatment of mental health disorders, mental health consultations and supervision, or the prevention of mental health disturbances. The definitions of telehealth and telemedicine are still evolving and often vary among states, organizations, licensing boards, and jurisdictions.‖ ―TelePsychology practices cover a wide range of services and modalities, including: • Crisis intervention or other contacts between in-person sessions.

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• Conducting sessions with patients who are not able to attend in person sessions because they are homebound due to physical or mental health issues, due to physical distance, lack of transportation or resources, or other reasons. • Providing assessment, consultation, supervision, prevention or treatment of mental disorders or related services to an individual in a different location with or without in-person face-to-face contact. • Conducting psychotherapy via phone or Internet synchronistically (i.e., at the same time, such as on the phone or via video-conferencing or virtual reality) or asynchronistically (i.e., sequential, via text, e-mail or chat). Telemedicine has been increasingly embraced by the medical communities and has been successfully implemented in preventative and nursing care, as well as in military, rural and forensic settings.‖ ―Efficacy of Telepsychology in the Digital Era There is ample evidence of the efficacy of TelePsychology. The most obvious is the more than half century of suicide crisis lines, where simple phone technologies have been effectively used for suicide prevention. Studies have shown that TelePsychology is effective it the treatment of anxiety, agoraphobia, PTSD, depression, and has been utilized effectively in consultation, supervision, and assessment.‖ Resistance to Change TelePsychology is highly suited as a delivery method for psychotherapy and counseling. These practices rely extensively on the spoken word and visual observation and generally do not require sophisticated medical and other technologies or physically intrusive medical interventions. Digital technologies dominate our social life, communication, leisure, play, commerce, and relationships. Despite this, psychologists and most other mental health providers have been, at best, slow to adapt, and more commonly, resistive to adapt. It is my opinion that such resistance is rooted in at least four factors: 1. Most psychologists are not highly technical and some are technology-resistant or even phobic. After all, we psychologists chose to get a doctorate in psychology and not in engineering, and we elect to focus on human behavior rather than on technology. 2. Many psychologists are in their 50-60s and, as such, belong to the group known as ―digital immigrants‖ (Zur & Zur, 2011). While most of the recent graduates entering the profession are ―digital natives‖ and feel comfortable with technology, the older generation, are more likely to fall within the ―reluctant digital immigrants‖ category. 3. Psychotherapists as a group have not been known to be highly adaptive or flexible. Many new ideas, approaches, and techniques are often met with

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resistance and skepticism. In spite of the token commitment to individual differences and cultural diversity, psychologists often fail to acknowledge or say ―This is foreign to me,‖ ―I don‘t understand,‖ or ―I am intimidated‖ but instead often say ―It is inappropriate and . . . unethical.‖ 4. Some of the main objections to phone, email, chat, virtual reality (VR), text or other non face-to-face forms of communication meet with the resistance of therapists who, rather tyrannically, claim that without being able to read body language, therapy is rendered obsolete. This argument is repeatedly made in spite of ample research demonstrating the efficacy of these techniques, and the psychological theories that describe the disinibition effect (when people are more likely to reveal personal information when there is no face-to-face contact), and the fact that some people prefer to be ‗side-by-side‘ without eye contact (one can argue that Freud was one of those). Obviously, TelePsychology is neither suited for all clients nor for all therapists, but it will work quite well for many. Most of the objections to TelePsychology are ideological, fearful, and baseless as they bluntly ignore the research of the efficacy of telementalhealth and disregard our commitment to honor, if not celebrate, individual and cultural diversity.‖ ―Summary As digital technologies continue to proliferate and dominate our lives in the 21st century, TelePsychology will become a major method of delivering mental health services. Obviously, the standard of care is still evolving and psychologists need to tolerate this transition period. Hopefully, psychologists realize that ―the train has left the station;‖ digital technologies dominate the way people communicate, play, learn, heal and connect. Telehealth has the potential to be less expensive and, therefore, more affordable. My hope is that psychologists recognize its value, find ways to overcome their fears of the new, eliminate their rigid loyalty to the familiar, and embrace these exciting new possibilities so we can serve our clients in the most helpful, effective, affordable, and readily available ways.‖

13. The following published article was reviewed: Using Skype For Qualitative Interview Research , by Janet K. Carter, Ph.D., CRC

―ABSTRACT Qualitative research seeks to gain understanding through an in-depth study of a research topic. This often requires in-depth interviews with individuals, and traditionally was done face-to-face. Researchers traveled to meet each participant at an agreed upon interview site. Skype is a free Voice over the Internet Protocol (VoIP) system that allows individuals to make video or audio calls. Skype used to use a peer-to-peer network, but when it was bought out by Microsoft, this changed to Linux machines owned by Microsoft. Users can Skype from computer to computer or from a computer to a phone. Researchers using this

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method of in-depth interviewing must consider the authenticity, confidentiality, and trustworthiness of the data collected. INTRODUCTION The explosion of the Internet across the globe has resulted in the rise of social media and new ways for people to communicate. It can also allow researchers to interview research participants anywhere in the world as long as the participant has access to a telephone or computer with a headset or webcam. This eliminates the need for travel and to find a private meeting location. Skype runs on Microsoft Windows, Linux and MacIntosh operating systems and also on Android, iPhone and Symbian phones. In addition, Panasonic and Samsung produce and market high-definition Skype-enabled televisions (Keen, 2011). According to the New York Times (Pfanner, 2010) in 2010 Skype had 124 million users a month with 40% making video calls. In 2011, there were a total of 700 million registered users (Aamoth, 2011). Skype software and computer-to-computer communications (including video calls) are free. For a small quarterly fee or purchase of Skype credit, users can also Skype from a computer to a cellular or land phone. Many smart phones now include a Skype application, allowing for free Skype to Skype calling through a wifi connection. Skype conversations are similar to using a speakerphone, because conversations can be heard through the computer speaker. If privacy is needed, researchers can use a headphone with a microphone so only the researcher will hear the participant‘s responses.‖ ―This chapter discusses how to use Skype for research interviews and potential issues in the use of Skype regarding the authenticity and confidentiality of the interview, informed consent and trustworthiness of the data.‖ ―USING SKYPE FOR RESEARCH INTERVIEWS Skype is easy to use. The first step is to download the software, next choose a Skype identity, and then make a free test call to test your connection. Next choose and download your recording software or set up your digital recorder. Add new contacts to your calling list by asking contacts for their Skype ID, clicking on the Contacts button, the Add button, and then add their Skype ID or phone number. This is stored as a list in your Skype phonebook. You can also search for contacts under the Contacts button. When you type in a name Skype will bring up a list of Skype members. This will include their hometown and country, if that information is stored on their user profile. Skype with friends and family several times to test the software, recording methodology, and become familiar with this process. Video calls require a webcam to be installed on both computers. Almost all new computers come with a video camera built in, but Skype also runs on older computers with a separate webcam attached. Once installed, any call can be a video call as long as both parties agree. Each person has the option to turn the video on or off using Skype commands, and it can be enlarged to full screen. Skype can be used for conference calls

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with up to 5 people on any computer or up to 10 people at a time using a PC with an Intel Duo Core Processor. To set up a conference call simply click the conference button in the Skype window and add the desired parties from your calling list. Arranging a Skype interview requires the researcher to contact the interviewee, obtain their Skype ID, and arrange a mutual date and time to call. Participants who agree to be interviewed would be entered into the researcher‘s Skype contact list. If the interview is across time zones, it is recommended the researcher use the time zone of the interviewee and then adjust their appointment reminder accordingly. At the agreed upon time, the researcher opens his or her Skype software, clicks on the contact‘s name and Skype will ring on the contact‘s computer. If there is a green light by the contact‘s name, then this contact is already on-line. If they do not answer, then the researcher may need to use other means to contact them and remind them of the appointment. Appointments can be set using the phone, e-mail, Facebook messages, or other agreed upon means. During the process of setting up the interview, it is critical to discuss the purpose of the research, how the information gathered in the interview will be used, the method of interview recording, how the interview data will be protected, the plan for protecting confidentiality (if desired by interviewee), and how and when recordings will be destroyed (if desired by interviewee). If the interviewee agrees to be recorded, then it is suggested that you set up your recording software to begin at the start of the call so you don‘t miss important information. Of course, at the very beginning of the call you must remind your participant that you are recording and can stop it at any time. Any recording software should allow you to do this, but you will need to know how it is done before you start your research.‖ ―Confidentiality and Skype Security Qualitative research participants have the right to privacy, and the right to request anonymity (Seidman, 2006). Therefore, if interviews are not face-to-face, participants

have the right to the assurance of reasonable data security even though interviews are being conducted using the Internet. Skype does encrypt messages Microsoft‘s stated policy for Skype is: ―Skype uses well-known standards-based encryption algorithms to protect Skype users' communications from falling into the hands of hackers and criminals. In so doing, Skype helps ensure user's privacy as well as the integrity of the data being sent from one user to another (Skype Security).‖ However, some computer experts state Microsoft may use automated scanning within Instant Messages and SMS to identify spam and links to sites engaged in phishing and other forms of fraud (Goodin, 2013). In addition, some countries, such as China, and law enforcement may be able to tap into communications (Gough, 2007). Thus, a researcher must consider the level of confidentiality required to protect the identity of each participant.

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Informed consent As with all qualitative research, research ethics require that all interviewees be provided with informed consent. Before an interview is conducted, the researcher must explain the purpose of the research, how the research will be recorded, how the information will be stored, and then how it will be destroyed. In my experience, interviewees were most concerned about video recordings. Once he or she agrees to participate, then it is important to open each interview with your informed consent statement and a reminder that interviews are being recorded. With Skype the participant always has the option to turn off the video conferencing and continue audio only and/or to stop the interview at any time. Thus, participating in the interview is entirely voluntary.

CASE STUDY My dissertation was a phenomenological research study of the psychosocial adaptation of female military veterans to traumatic amputation. My budget was limited, and participants were located all over the United States. Thus, I developed a research model that allowed me to interview each participant at her home and preferred time. I used a MacBook with Skype and Call Recorder software. I set Call Recorder to start recording as soon as the Skype called was answered. Next, I thanked each woman for participating and reminded her that the call was being recorded. I stated the recording could be stopped at any time. Skype calls allowed me to interview each woman at a time that fit her schedule. Some interviews were broken into segments, others lasted for up to two hours. The research protocol called for 90 minutes per participant. Some calls were Skype to Skype and others were Skype to phone with the participant determining the type of call. If a participant needed a webcam to participate, one was purchased and shipped to her. While I preferred Skype video calls, some participants preferred Skype to phone. One of my participants was very active in para sports and was able to show me her running leg using the Skype video call. She was able to lift it up so that I could see it on the screen while she described the different components. Another participant lost both of her arms above her elbow as a bomb disposal expert and found it easier to talk via phone than computer. Skype allowed me to adjust to the preferences of each participant.‖ ―In my experience, this format did not affect my ability to establish trust with each participant. By discussing the purpose of my research, how I planned to use the interview data, and how their data would be stored and then destroyed when the women were initially asked to participate…trust was built from the very first contact. While it is possible the women may have been more disclosing if we had met face-to-face, Leibert, Archer, & Munson, et al. (2006) reported that while Internet counseling lacks access to full body nonverbal language, this was offset by the client‘s greater willingness to share his or her personal history. Schultze (2006) reported that individuals using Internet counseling reported they felt more comfortable communicating from home than in a counselor‘s office. In addition, Schultze reported the client felt ‗subjective-protectiveness‘ or

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psychological anonymity. Thus, early research on the use of Skype for counseling suggests this format does not inhibit disclosure, and may even encourage participants to be more open. Future research directions With the increasing acceptance of Internet communications, it is expected that more and more researchers will use Skype or other VoIP transmissions in interview research. The United States Department of Veteran Affairs (VA) currently uses telemedicine to provide medical services to veterans living in remote areas. Since Internet service is often not readily available in rural America, the VA uses a communication device attached to a telephone (Opsahl, 2010). In addition, the VA is now offering telemental health to veterans. Telemental health includes e-mails, blogs, websites, and virtual reality treatments for anxiety disorders and pain management (VA.gov, 2007). The VA is currently recruiting telemental health psychologists to expand telemental health services into clinical video teleconferencing. As the Internet access expands into more communities, Skype offers researchers a cost-effective and time saving method to conduct individual interviews around the world. It could also be used to conduct small focus groups with participants located across the nation or globe. As long as standard qualitative ethical practices are used, Skype offers researchers the technology to simulate face-to-face interviews with video conferencing without sacrificing the quality of data collection.‖

14. The following was reviewed: CODE OF PROFESSIONAL ETHICS FOR REHABILITATION COUNSELORS, Adopted in June 2009 by the Commission on Rehabilitation Counselor Certification for its Certified Rehabilitation Counselors; This Code is effective as of January 1, 2010.

―SECTION J: TECHNOLOGY AND DISTANCE COUNSELING J.1. BEHAVIOR AND IDENTIFICATION

a. APPLICATION AND COMPETENCE. Rehabilitation counselors are held to the same level of expected behavior and competence as defined by the Code regardless of the technology used (e.g., cellular phones, email, facsimile, video, audio, audio-visual) or its application (e.g., assessment, research, data storage). J.12. DISTANCE COUNSELING RELATIONSHIPS

a. BENEFITS AND LIMITATIONS. Rehabilitation counselors inform clients of the benefits and limitations of using technology applications in the counseling process and in business procedures. Such technologies include, but are not limited to, computer hardware and/or software, telephones, the Internet and other audio and/or video communication, assessment, research, or data storage devices or media.‖

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15. The following was reviewed: AMERICAN BOARD OF VOCATIONAL EXPERTS CODE OF ETHICS, Revision adopted by ABVE Board of Directors, August 2007.

―Forensic Work Activity – In this setting, the professional conducting the forensic assessment and analysis is not expected to provide direct services to the person with the disability or impairment, to implement a rehabilitation plan or to act as a resource person subsequent to the litigation. The Client - In a forensic setting, the professional who is engaged as an expert witness has no client. The ultimate role of the expert in a forensic setting is to communicate the truth of the matter as the expert sees it. Expert opinions should be based on sound methodology and empirical data. Experts do not advocate for, or attempt to preserve the interests of, the person being evaluated, an attorney or any other party in the legal matter. Experts use their unique specialized knowledge and skills to analyze the empirical data, to generate hypotheses, test their validity against the facts and to use their skilled clinical judgment to express opinions that reflect on the issues at hand. R5.5 Vocational Experts will obtain permission from the Referral Source evaluees, or their legal representative, prior to taping or otherwise recording interviews, testing, or counseling sessions. R6.3 Vocational Experts will ensure that the administration of tests is performed under the same conditions that were established in the standardization process. When tests are not administered under standardization process, as may be necessary to accommodate modifications for individuals with disabilities or when unusual behavior or irregularities occur during the testing session, these conditions must be noted and discussed at the time of interpretation.‖

Are face to face, in person meetings required during a vocational session? Not according to the Commission on Rehabilitation Counselor Certification for its Certified Rehabilitation Counselors (CRCC) or the American Board of Vocational Experts (ABVE).

SUMMARY Our thorough research regarding the use of Skype and Skype‘s security policies have brought us to the following conclusions: - Anything on the internet can be hacked; however, Skype protects its users with internationally recognized methods of encryptions and has withstood tests of time over many years. Skype protects its users against malicious attackers and eavesdroppers. They even issue each user with a ―Digital Certificate‖ and authentication processes. - Skype uses well-known standards-based encryption algorithms to protect Skype users' communications from falling into the hands of hackers and criminals. In so doing, Skype helps ensure user's privacy as well as the integrity of the data being sent from one user to another.

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-Skype does collect content from instant messages, voicemails, and video messages; however, Skype will only share this information when Skype feels that it is in good faith in order to comply with applicable law or respond to valid legal process from competent authorities, including from law enforcement or other government agencies, protect our customers, for example to prevent spam or attempts to defraud users of the services, or to help prevent the loss of life or serious injury to anyone; operate and maintain the security of our services, including to prevent or stop an attack on our computer systems or networks.

- Any information collected by Skype is found in our public profiles– they do not eavesdrop on video calls at any time. The only time Diaz & Company discloses private information of clients (i.e. Identification card, social security number) is during the video call. Again, video calls are not recorded or stored, and video calls are highly protected by Skype‘s internationally recognized methods of encryption. - Skype may scan users‘ Instant Messages and SMS; however, Diaz & Company never utilizes Instant Messaging and SMS during our vocational evaluations. - Any information collected by Skype from our public profiles, Instant Messages, or SMS is mainly for the purpose of sending out surveys, advertisements, and fixing technological issues – it is never for malicious purposes. - Any information collected by Skype from our public profiles, Instant Messages, or SMS will never be sold, rented, or traded with other companies. - In all likelihood, levels of advancement in non-malicious technology have been increasing at incredible rates, and, in turn, protection levels will be advancing significantly over time. - Currently, there is nation-wide usage of CourtCall, Remote Court Appearances. There is also video teleconferencing with the use of Skype throughout the country by Therapists, Counselors, and Psychiatrists. This substantiates the use of video conferencing, both for legal as well as medical matters. - Skype and other forms of teleconferencing allows practitioners and counselors to contact clients and patients who are not easily accessible, either by living in a distant area or being unable to drive/travel due to immobilizing injuries. Having an immobilizing injury should not mean that you cannot receive professional aid from practitioners, counselors, and even doctors. The use of Skype for medical and health practices is an example of adapting a commonly available technology for delivering care services. - Appropriate use of ―telehealth‖ could contribute to mitigating the unequal distribution of resources. - Recourse to remote treatment provides many advantages, such as increased and quicker accessibility to health care services for people who live outside major urban centers as well as reduced wait lists, travel time, and transportation costs.

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- As digital technologies continue to proliferate and dominate our lives in the 21st century, video conferencing will become a major method of communication in both medical and legal fields. Obviously, the standard of care is still evolving and medical/legal professionals need to tolerate this transition period. Hopefully, medical/legal professionals realize that ―the train has left the station.‖ Digital technologies dominate the way people communicate, play, learn, heal and connect. - Video Conferencing has the potential to be less expensive and, therefore, more affordable. We must recognize its value, find ways to overcome fears of the new, eliminate rigid loyalty to the familiar, and embrace these exciting new possibilities so we can serve our clients in the most helpful, effective, affordable, and readily available ways. - Based on the Code of Professional Ethics for the Rehabilitation Counselors, Rehabilitation counselors are held to the same level of expected behavior and competence as defined by the Code regardless of the technology used (e.g., cellular phones, email, facsimile, video, audio, audio-visual) or its application (e.g., assessment, research, data storage). - In order to successfully utilize Skype for Vocational Consultations, a few security and ethical measures must be met:

1. Must complete an informed consent with your interviewee at the beginning of your evaluation. Your informed consent must inform the interviewee of how the evaluation is being conducted; what risks are associated with conducting the evaluation on a video conference; how the data collected during the evaluation will be used by the vocational expert; etc. 2. Do not record your evaluations. If you do, this must be informed to your interviewee, and also inform how the information recorded will be used, stored, and/or destroyed. 3. The Vocational Consultant should use a headphone with a microphone in order to allow privacy for answers by the interviewee. This will prevent anyone near the Vocational Consultant from being able to hear or eavesdrop on the responses of the interviewee. 4. Although Skype never records or eavesdrops on video conferences, do not have the interviewee repeat their social security number on the video call. You may confirm the last four digits.

I declare under penalty of perjury that the information contained in this report and its attachments, if any, is true and correct to the best of my knowledge, except as to information that I have indicated I received from others. As to that information, I declare under penalty of perjury that the information accurately describes the information provided to me and, except as noted herein, that I believe it to be true. I further declare under penalty of perjury that there has not been a violation of Labor Code section 139.32. The information contained in this report, and all attachments, is confidential, privileged, and may also be proprietary business information that is intended only for the personal and confidential use of the recipient(s) named above. If the reader of this report is not the intended recipient or an agent responsible for delivering it

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to the intended recipient, you are hereby notified that you have received this report in error and any review, dissemination, distribution or copying of this report is strictly prohibited. If you received this communication in error, please notify the sender immediately, and delete the original report.

Signed in the County of San Mateo, California on ________________________________________.

Respectfully submitted, Frank P. Diaz, CDMS Vocational Expert FPD:sk